AHRQ Patient Safety Network

The Collection > Epidemiology of Errors and Adverse Events

PATIENT SAFETY PRIMERS
Never Events
Adverse Events after Hospital Discharge

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Safety Target

•Device-related Complications (59)

•Diagnostic Errors (90)

•Identification Errors (55)

•Discontinuities, Gaps, and Hand-Off Problems (129)

•Fatigue and Sleep Deprivation (18)

•Medication Safety (479)

•Medical Complications (164)

•Nonsurgical Procedural Complications (24)

•Surgical Complications (231)

•Transfusion Complications (12)

•Psychological and Social Complications (26)

Origin/Sponsor

•Africa (4)

•Asia (33)

•Australia and New Zealand (80)

•Central and South America (7)

Resource Types

•Clinical Guideline (1)

•Journal Article (1087)

•Legislation/Regulation (4)

•Meeting/Conference (1)

•Newsletter/Journal (1)

•Newspaper/Magazine Article (28)

•Press Release/Announcement (2)

•Special or Theme Issue (2)

•Tools/Toolkit (1)

•Web Resource (11)

Error Types
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Epidemiology of Errors and Adverse Events

Approach to Improving Safety

•Quality Improvement Strategies (240)

•Legal and Policy Approaches (49)

•Error Reporting and Analysis (480)

•Communication Improvement (205)

•Human Factors Engineering (126)

•Teamwork (48)

•Specialization of Care (74)

•Logistical Approaches (71)

•Culture of Safety (88)

•Technologic Approaches (210)

•Education and Training (159)

Clinical Areas

•Allied Health Services (4)

Target Audience

•Health Care Providers (910)

•Health Care Executives and Administrators (1009)

•Non-Health Care Professionals (359)

•Patients (34)

Setting of Care

•Hospitals (877)

•Psychiatric Facilities (6)

•Residential Facilities (27)

•Ambulatory Care (129)

•Outpatient Surgery (17)

•Patient Transport (16)

1 - 20 of 1178

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STUDY

The impact of trained assistance on error rates in anaesthesia: a simulation-based randomised controlled trial.

Weller JM, Merry AF, Robinson BJ, Warman GR, Janssen A. Anaesthesia. 2009;64:126-130.

STUDY

Barriers to adverse event and error reporting in anesthesia.

Heard GC, Sanderson PM, Thomas RD. Anesth Analg. 2012;114:604-614.

STUDY

Multimodal system designed to reduce errors in recording and administration of drugs in anaesthesia: prospective randomised clinical evaluation.

Merry AF, Webster CS, Hannam J, et al. BMJ. 2011;343:d5543.

STUDY

Surgeon's vigilance in the operating room.

Zheng B, Tien G, Atkins SM, et al. Am J Surg. 2011;201:667-671.

STUDY

Optimising surgical training: use of feedback to reduce errors during a simulated surgical procedure.

Boyle E, Al-Akash M, Gallagher AG, Traynor O, Hill AD, Neary PC. Postgrad Med J. 2011;87:524-528.

COMMENTARY

What happens when things go wrong?

Brandom BW, Callahan P, Micalizzi DA. Paediatr Anaesth. 2011;21:730-736.

STUDY

Quality improvement project to reduce perioperative opioid oversedation events in a paediatric hospital.

Vermaire D, Caruso MC, Lesko A, et al. BMJ Qual Saf. 2011;20:895-902.

STUDY

Critical incident reports concerning anaesthetic equipment: analysis of the UK National Reporting and Learning System (NRLS) data from 2006-2008.

Cassidy CJ, Smith A, Arnot-Smith J. Anaesthesia. 2011;66:879-888.

STUDY

Distractions and the anaesthetist: a qualitative study of context and direction of distraction.

Jothiraj H, Howland-Harris J, Evley R, Moppett IK. Br J Anaesth. 2013 Apr 16; [Epub ahead of print].

COMMENTARY

Vial Mistakes Involving Heparin.

Vanderveen T. AHRQ WebM&M [serial online]. May 2009.

STUDY

What is the safety of nonemergent operative procedures performed at night?

Turrentine FE, Wang H, Young JS, Calland JF. J Trauma. 2010;69:313-319.

STUDY

Representative case series from public hospital admissions 1998 II: surgical adverse events.

Briant R, Morton J, Lay-Yee R, Davis P, Ali W. N Z Med J. 2005;118:U1591.

STUDY

Communication failure in the operating room.

Halverson AL, Casey JT, Andersson J, et al. Surgery. 2011;49:305-310.

STUDY

Infrequent physician use of implantable cardioverter-defibrillators risks patient safety.

Lyman S, Sedrakyan A, Do H, Razzano R, Mushlin AI. Heart. 2011;97:1655-1660.

STUDY

Safety on an inpatient pediatric otolaryngology service: many small errors, few adverse events.

Shah RK, Lander L, Forbes P, Jenkins K, Healy GB, Roberson DW. Laryngoscope. 2009;119:871-879.

STUDY

A policy-based intervention for the reduction of communication breakdowns in inpatient surgical care: results from a Harvard surgical safety collaborative.

Arriaga AF, Elbardissi AW, Regenbogen SE, et al. Ann Surg. 2011;253:849-854.

STUDY

No harm found when nurse anesthetists work without supervision by physicians.

Dulisse B, Cromwell J. Health Aff (Millwood). 2010;29:1469-1475.

STUDY

Bariatric surgery with operating room teams that stayed fixed during the day: a multicenter study analyzing the effects on patient outcomes, teamwork and safety climate, and procedure duration.

Stepaniak PS, Heij C, Buise MP, Mannaerts GHH, Smulders JF, Nienhuijs SW. Anesth Analg. 2012;115:1384-1392.

STUDY

Effect of a 19-item surgical safety checklist during urgent operations in a global patient population.

Weiser TG, Haynes AB, Dziekan G, et al; Safe Surgery Saves Lives Investigators and Study Group. Ann Surg. 2010;251:976-980.

STUDY

Factors that influence the expected length of operation: results of a prospective study.

Gillespie BM, Chaboyer W, Fairweather N. BMJ Qual Saf. 2012;21:3-12.

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